No Need for Surgery in Many Cases of CRC Metastases
August 12, 2009
Orlando-Patients with metastatic colorectal cancer (CRC) can generally avoid surgery to remove the primary tumor before starting chemotherapy, according to the 6-year experience from Memorial Sloan-Kettering Cancer Center (MSKCC).
"Routine surgery to remove the primary tumor in patients with unresectable metastases is no longer supported by the data," said Philip Paty, MD, attending surgeon and vice chairman of clinical research at MSKCC.
Surgery to remove the primary tumor is known to be of uncertain benefit; nonetheless, it is a common practice in many centers. The rationale is that surgery prevents future complications, such as obstruction, bleeding, and perforation, explained Paty, the study’s lead author. "There are little data that quantitate the results of not surgically intervening," he said.
He and his colleagues therefore performed a retrospective analysis to review the safety and efficacy of avoiding resection of the primary tumor. The study included 233 consecutive patients presenting with metastatic CRC between 2000 and 2006 who underwent standard chemotherapy (some received bevacizumab as well) but not surgery. Patients were free of local symptoms from their tumor.
Of the 233 patients, 207 (89%) never developed colon problems that required urgent surgery. Ten (4%) developed colon obstruction that was successfully treated with stents or radiation, rather than surgery. Sixteen (7%) did require nonelective colon surgery for obstruction (n = 13) or perforation (n = 3).
Two patients (0.8%) died due to the surgical intervention, which was considered within the norm. "This compares favorably to historical data showing a mortality rate of 1% to 5% with up-front surgery that is done routinely," Paty pointed out.
Overall, therefore, 93% of patients never required colon surgery to treat complications from their primary tumor. These patients were able to begin chemotherapy immediately, thus avoiding the high cost and the risks associated with surgery.
"We believe a nonsurgical approach should become standard practice," Paty said at a press conference.
Nicholas Petrelli, MD, of Thomas Jefferson University, Philadelphia, who chaired the press conference on gastrointestinal cancers, commented that many asymptomatic patients are getting surgery, often unnecessarily. These results have implications for these patients and their physicians, he said.
An ongoing multicenter clinical trial conducted by the National Surgical Adjuvant Breast and Bowel Project will evaluate this issue more fully by comparing up-front surgery for the primary tumor versus no surgery in patients with asymptomatic primary tumors and metastases.
-Caroline Helwick
